Medical Claims Analyst Job Description and Profile

The medical claims analyst work in health insurance or government companies to ensure that the claims received are valid. He or she determines whether the insurance company will make the claimed payment to the doctors or the hospitals. The medical claim analyst reviews the medical bills for the accuracy of the treatments, tests, and hospital stays prior to sanctioning the claims. In case there are any queries, the analyst collects additional documents and conducts further investigation. He or she is responsible for identifying inaccuracies in claims that have been paid while working with third-party billing agencies to resolve discrepancies.

Medical Claims Analyst Duties and Responsibilities

Reviewing billing information to check for accuracy and correctness

Investigate further in case of discrepancy of information

Verifying the documentation and other documentation provided by the claimant

Knowledgeable about medical terms, practices, and pharmaceuticals

Settling claims in accordance to company rules and regulations

Conferring with the legal counsels on claims that require litigation

Medical Claims Analyst Education, Training, and Qualifications

A majority of the employers requires an individual to possess a bachelor degree in nursing or any other medical related field. In case, a person aspires to work as a medical claims analyst with an insurance company, prior experience in claims adjustments is necessary. A degree in physician assistant or pharmacy is also preferred by some employers that hire medical claims analyst. Some experience in reviewing, authorizing, and monitoring medical services is an added benefit to succeed as a medical claims analyst.

Medical Claims Analyst Degrees, Courses, and Certification

A bachelor’s degree in nursing, pharmacy, or physician assistant is essential for a medical claims analyst profile. Courses providing training on working with automated reviewing and data analysis systems are preferable. Furthermore, completing a course that provides knowledge of the various health care standards is beneficial. Knowledge on billing procedures and standards is beneficial. Any other course that imparts training on workers compensation, report making, effective communication, and working with legal counsels are preferred by companies.